Education and imaging. Hepatobiliary and pancreatic: giant gallbladder associated with Byler's disease

Giant gallbladder case report with vascular endothelial growth factor (VEGF) serum level and mRNA expression evaluation

Giant gallbladder (GGB) is a rare condition and its pathogenesis could not be explained clearly. It can result from cholelithiasis, chronic cholecystitis or neoplasm, but more rarely if created congenitally. Adequate vasculatization should support the development of this entity. A 47-year-old lady presented with a dull pain and right upper quadrant abdominal mass. A computed tomography scan showed 27 × 25 × 12 cms cystic mass expanding to the right illiac fossae, surrounded by a homogenous capsule. There were neither stones nor mass in the biliary tract and total cholecystectomy was done. Patient recovered well without signs of cholestasis 5 years postoperatively. A few cases of giant benign gall bladder have been reported in literature; however, no study has tried to investigate the mechanism of its etiology. To support the enlargement of the tissue or organ there must be some growth factors along with adequate vascularization. Vascular endothelial growth factor (VEGF) serum level and VEGF messenger ribonucleic acid (mRNA) gene expression were increased in this case. This GGB case suggests a congenital factor as its etiology. Cholecystectomy may relieve uncomfortable symptoms with good results. The incidence of GGB accompanied by increased serum VEGF levels and mRNA gene expression supports the hypothesis that VEGF plays a major role in supporting the vasculogenesis of GGBs.

The giant resectable carcinoma of gall bladder-a case report

Background

Gall bladder cancer (GBC) is the fifth most common malignancy in the gastrointestinal system and the most common malignancy of the biliary system. GBC is a very aggressive malignancy having a 5 year survival rate of 19%. Giant Gall Bladder (GGB) is an uncommon condition that can result from cholelithiasis or chronic cholecystitis and rarely with malignancy.

Case report

A 65 year old lady presented with vague abdominal pain for 12 years and right abdominal lump of size 20 × 8 cms was found on examination. CT scan showed a circumferentially irregularly thickened wall (2.5 cm) of gall bladder indicative of malignancy. Per-operatively a GB of size 24 × 9 cm was noted and patient underwent radical cholecystectomy. It was surprise to find such a giant malignant GB with preserved planes. Histopathology, it was well differentiated adenocarcinoma of gall bladder of Stage II (T2a N0 M0).

Discussion

It is known that mucocoele of GB can attain large size, however chronic cholecystitis will lead to a shrunken gall bladder rather than an enlarged one. A malignant GB of such size and resectable is rare without any lymph node involvement or liver infiltration. Few cases of giant benign gall bladder have been reported in literature, however this appears to be the largest resectable gall bladder carcinoma reported till date as per indexed literature.

Conclusion

Giant GB is an uncommon finding. They are mostly benign, however malignant cases can occur. Radiological findings may suggest features of malignancy and define extent of disease. Prognosis depends on stage of disease and resectability, irrespective of size.

Giant Gallbladder Revealed by Chronic Cholecystitis Gallstone: A Case Report and Review of the Literature

We report here an extremely rare case of giant gallbladder and discuss diagnostic circumstances and different ethiopathogenic theories. A 53-year-old woman presented acute right hypochondrium pain. Ultrasonography showed a huge cystic mass with gallstones and a CT scan confirmed the diagnosis of giant gallbladder. Cholecystectomy was performed. Outcomes were uneventful and histopathological examination of the specimen confirmed the presence of chronic cholecystitis. Enlargement of the gallbladder is related to biliary retention. This enlargement is favored by the slow evolution of malignant pathologies. However, some benign situations have been reported in the literature, and giant gallbladder can occur in a benign situation even if its ethiopathogeny is not so clear.

Huge gangrenous gallbladder presenting as gastro-esophageal reflux disease successfully treated by laparoscopic cholecystectomy: Case report and literature review

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“Giant” gallbladder development in the context of acute on chronic cholecystitis is extremely rare and may present with atypical symptoms secondary to mass effect.

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Current grading systems for acute cholecystitis severity do not include assessment based on size making them insufficient in predicting “giant” gallbladder surgical prognosis.

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Laparoscopic cholecystectomy was performed successfully despite the large gallbladder size without intraoperative/postoperative complications.

Introduction

Gallbladder disease is a common surgical pathology. Gallstones can remain asymptomatic or develop into an acute cholecystitis and need for surgical intervention. Significant enlargement of the gallbladder well beyond the normal volume is rare. Such “giant” gallbladders can affect feasibility of subsequent management options.

Presentation of case

An 80-year-old female presented to the emergency department with a two-day history of acute on chronic gastric reflux with nausea and vomiting. On examination, she had right upper quadrant abdominal pain. CT imaging identified an enormous gallbladder creating mass effect and compression on the distal stomach. She underwent successful laparoscopic cholecystectomy and was discharged from the hospital the next day, doing well. On two-week follow up, her reflux symptoms had completely resolved and she had no complaints.

Discussion

Giant gallbladders are a rare entity. Our patient’s case is unique in both its occurrence as well as presentation with predominant reflux symptoms secondary to mass effect by the enlarged gallbladder. Current cholecystitis grading systems do not utilize size as a means of predicting severity and risk of operative complications or difficulty of procedure. Laparoscopic cholecystectomy was a successful approach in managing this extreme pathology.

Conclusion

Updated classifications systems that include size and mass effect as a predictive measure are needed to better assess surgical outcomes, especially in “giant” gallbladder disease. Despite the large size and potential mass effect on surrounding structures, laparoscopic cholecystectomy can still be attempted if no other contraindications exist.

Cholecystomegaly: A Case Report and Review of the Literature

Chronic cholecystitis or symptomatic gallbladder is a prolonged mechanical or functional disorder of abnormal gallbladder emptying. Most of the patients have recurrent pain attacks (acute biliary colic), but when pain lasts more than 24 hours, it requires urgent surgical intervention (acute cholecystitis). The length of a fully distended gallbladder is about 7 to 10 cm. We report a case of a huge and severely inflamed gallbladder, as we have just found only a few previous case reports of the huge gallbladder in the literature. This case report and review may help to find a mechanism for the development of a giant gallbladder. The patient was a 36-year-old woman, who had been known to have a symptomatic gallstone for at least three years. The patient underwent laparotomy, and a giant 22 cm roundish severely inflamed and overdistended gallbladder with wall thickening and tight adhesion to adjacent organs was found under the right liver lobe. Femininity and diabetes seem to be risk factors for developing a huge gallbladder, and several hypotheses are encountered: (1) a long-lasting obstructed cystic duct or biliary tree, and accumulation of mucosal secretion from the gallbladder epithelium, (2) an obstructed hepatic/cystic duct junction with a stone acting like a check valve and bile trapping mechanism, and (3) gallbladder dysfunction and cholecystoparesis affecting through reduced cholecystokinin and celiac parasympathetic nerve disturbance in diabetes and diabetic autonomic neuropathy. Open cholecystectomy is the technique of choice in surgical excision of a huge gallbladder; however, laparoscopy could be performed by expert hands.

Giant Gallbladder Presenting as a Right Iliac Fossa Mass Removed by Mini-laparoscopic Cholecystectomy

Giant gallbladder (GGB) is a rare condition that can result from cholelithiasis or chronic cholecystitis. Although there are no clear-cut definitions, gallbladders of >14 cm and ≥1.5 L have been regarded as GGBs. To date, most GGBs have been managed by laparotomic removal. This report describes a patient with a GGB that presented as a right iliac fossa mass. The GGB was successfully removed by mini-laparoscopic cholecystectomy. A 63-year-old woman presented with painful swelling in her right lower abdomen associated with dyspepsia and a palpable right iliac fossa mass. Computed tomography of the abdomen revealed a markedly enlarged gall bladder (19.5 x 5.4 x 5.6 cm) containing stones. Magnetic resonance cholangiopancreatography ruled out extra- and intrahepatic ductal dilatation and stones. She underwent a mini-laparoscopic cholecystectomy, and her postoperative recovery was uneventful.

Constitutive Androstane Receptor Differentially Regulates Bile Acid Homeostasis in Mouse Models of Intrahepatic Cholestasis

Bile acid (BA) homeostasis is tightly regulated by multiple transcription factors, including farnesoid X receptor (FXR) and small heterodimer partner (SHP). We previously reported that loss of the FXR/SHP axis causes severe intrahepatic cholestasis, similar to human progressive familial intrahepatic cholestasis type 5 (PFIC5). In this study, we found that constitutive androstane receptor (CAR) is endogenously activated in Fxr:Shp double knockout (DKO) mice. To test the hypothesis that CAR activation protects DKO mice from further liver damage, we generated Fxr;Shp;Car triple knockout (TKO) mice. In TKO mice, residual adenosine triphosphate (ATP) binding cassette, subfamily B member 11 (ABCB11; alias bile salt export pump [BSEP]) function and fecal BA excretion are completely impaired, resulting in severe hepatic and biliary damage due to excess BA overload. In addition, we discovered that pharmacologic CAR activation has different effects on intrahepatic cholestasis of different etiologies. In DKO mice, CAR agonist 1,4‐bis[2‐(3,5‐dichloropyridyloxy)]benzene (TCPOBOP; here on TC) treatment attenuated cholestatic liver injury, as expected. However, in the PFIC2 model Bsep knockout (BKO) mice, TC treatment exhibited opposite effects that reflect increased BA accumulation and liver injury. These contrasting results may be linked to differential regulation of systemic cholesterol homeostasis in DKO and BKO livers. TC treatment selectively up‐regulated hepatic cholesterol levels in BKO mice, supporting de novo BA synthesis. Conclusion: CAR activation in DKO mice is generally protective against cholestatic liver injury in these mice, which model PFIC5, but not in the PFIC2 model BKO mice. Our results emphasize the importance of the genetic and physiologic background when implementing targeted therapies to treat intrahepatic cholestasis.

Giant gallbladder: A case report and review of literature

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Reports of giant gallbladders are rare and do not exceed eight cases worldwide.

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We presented here a case of a giant gallbladder and review of literature.

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We define a gallbladder as ‘giant’ if the volume of the organ exceeds 1.5 L.

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A giant gallbladder may develop patients of any age, mimicking an abdominal tumour.

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Diagnostics and treatment of a giant gallbladder demand non-routine approaches.

INTRODUCTION

Reports of a giant gallbladder are rare.

PRESENTATION OF CASE

A 77-year-old woman was admitted with complaints of dull pain in the right half of the abdomen and a palpable mass at the same place. A computerized tomography scan revealed an extremely enlarged gallbladder. Open cholecystectomy was performed. The volume of the removed organ was as much as 3.35 L.

Follow-up after 18 months showed that the patient was well. Examination revealed no significant acquired or congenital anomalies that might explain the excessive enlargement of the gallbladder.

DISCUSSION

We define a ‘giant’ gallbladder as an extreme enlargement of the organ with a volume exceeding 1.5 L, so that its weight is comparable to or even exceeds the mean (estimated) weight of the adult liver (1.5 kg). The first clinical presentation of such an enlargement is likely to differ from any other gallbladder disease, but rather to resemble a tumour or cyst of the abdominal cavity.

CONCLUSION

A giant gallbladder is a special clinical and pathological entity in surgical practice, of unknown origin. It may develop in patients of any age, and mimics a large abdominal tumour or peritoneal cyst. Both the diagnostic process and surgical treatment demand non-routine approaches. Early and late follow-up results seem to be favourable.

A case of congenital giant gallbladder with massive hydrops mimicking celiac cyst

We present a case of a 55-year-old female who suffered from a mass in the right upper abdomen, which had been present for over six months. Pre-operative blood examinations, including tumor markers, were normal. Initially, the admitting diagnosis was a giant celiac cyst, due to its liquid cystic appearance and large size (approximately 30.0×18.0 cm), visible in the hepatic region under ultrasound. Following the discovery of a cystic duct during surgery, the diagnosis was corrected to be a giant gallbladder. As no obstructive matter was observed, the giant gallbladder was considered to be congenital.